Nokea
The nurse is assigned a client with calcium level of $4.0 \mathrm{mg} / \mathrm{dL}$. Which system assessment would the nurse ask detailed questions?
- A. Endocrine system
- B. Gastrointestinal system
- C. Neurological system
- D. Musculoskeletal system
Correct Answer: C
Rationale: A client with a calcium level of $4.0 \mathrm{mg} / \mathrm{dL}$ has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.
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The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage?
- A. A grilled chicken sandwich with mayonnaise
- B. A natural fruit salad with nuts
- C. A hot dog with ketchup
- D. A fresh grilled tuna entr?©e with fresh asparagus
Correct Answer: C
Rationale: Foods high in sodium include processed meats, such as hot dogs and cold cuts; fast foods; frozen meals; cheeses; soups and juices; and salted snack foods to name a few.
An adult client is brought into the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next?
- A. Continue to monitor client with another appointment.
- B. Be prepared to administer a lactated Ringer's IV.
- C. Be prepared to administer a sodium chloride IV.
- D. Consider sodium restriction with discontinuation of salt tablets.
Correct Answer: D
Rationale: The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only worsen this condition. A Lactated Ringer's IV is a hypertonic IV and is not used with hypernatremia. A hypotonic solution IV may be a part of the treatment, but not along with the salt tablets.
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?
- A. vital signs
- B. edema
- C. intake and output
- D. weight
Correct Answer: D
Rationale: Daily weight provides the ability to monitor fluid status. A 2-lb $(0.9 \mathrm{kg})$ weight gain in 24 hours indicates that the client is retaining $1 \mathrm{~L}$ of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.
A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?
- A. Slow heart rate
- B. Kidney stones and blood clots
- C. Imbalance in electrolytes
- D. Elevated central venous pressure (CVP)
Correct Answer: B
Rationale: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below $4 \mathrm{~cm} \mathrm{H}_2 \mathrm{O}$.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?
- A. Abnormal potassium level
- B. Elevated hematocrit level
- C. Low white blood count
- D. Low urine specific gravity
Correct Answer: B
Rationale: When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.